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Based on interview and record review, the facility failed to implement their policies and procedures (P&P) for six of 30 sampled patients (Patient 1, 2, 11, 14, 19, and 28) when:

1. For Patient 1, the nurse did not notify the physician and primary nurse of vital information to determine if Patient 1 was a danger to self; (Refer to A-398)

2. For Patients 2, and 11, pain was not reassessed within 60 minutes after administration of pain medication; (Refer to A-398)

3. For Patient 11, the nurse changed the standard alarm limits (50-120) to 40 on the cardiac monitoring machine without a physician order; (Refer to A-398)

4. For Patient 14, the nurse did not notify the physician when Patient 14's heart rate parameter fell below the standard alarm limit of 50 on the cardiac rhythm strips; (Refer to A-398)

5. For Patients 14 and 28, the primary nurse did not verify, validate and sign the cardiac rhythm strips; (Refer to A398)

6. For Patient 19, pain medications were not administered for pain rated eight out of 10 (pain level, describes severity of pain, zero meaning no pain and 10 meaning the worst pain possible); (Refer to A-398)

7. For Patient 28, there was no care plan to address restraints; and (Refer to A-398)

8. For Patient 28, the nurse did not document vital signs (a measurement which shows how well your body is working and includes, heart rate, temperature, blood pressure, and respiration) in a timely manner. (Refer to A-398)

The cumulative effects of these systemic failures had the potential to impact the health, safety, and treatment of the patients, poor pain management and may cause delays in the provision of patient care and/or death.

Based on interview and record review, the facility failed to prevent one patient (Patient 2) from being misgendered and not addressed by her preferred pronoun by multiple staff members.

This failure had the potential to impact the health, treatment of patients, and cause emotional harm to other patients and may cause delays in the provision of patient care.

Findings:

On March 3, 2025, an unannounced visit was conducted at the facility for a complaint validation survey.

A review of Patient 2's medical record was conduct with the Chest Pain Coordinator (CPC) on March 4, 2025. A review of the facility document titled, "ED [emergency department] Note-Physician," dated February 18, 2025, indicated, Patient 2 was a Transgender female, with pronouns of she/her, past medical history multiple gender affirming surgeries, on hormone replacement therapy, brought in by ambulance due to pain around surgical drain. Patient recently had "tummy tuck" and was scheduled for drain removal today but she awoke this morning with sudden onset sharp pain around the right surgical drain.

An interview was conducted with the Nursing House Supervisor (NHS) on March 4, 2025, at 3:43 p.m. The NHS indicated, Patient 2 was called by the wrong pronoun by staff and the Director of Emergency Department (DED) and Clinical Nurse Manager (CNM) had spoke with Patient 2 regarding the incident. Patient 2 was called the wrong pronoun again by different staff during the same shift, at which time Patient 2 requested to speak with the NHS. The NHS stated she apologized to Patient 2 for multiple staff using the wrong pronouns. The NHS further stated Patient 2 indicated, Registered Nurse 2 (RN 2) used a tone and said the wrong pronoun on purpose because she did not like her.

An interview was conducted with the DED on March 4, 2025, at 4:05 p.m. The DED stated RN 2's comments to Patient 2 were not appropriate, and the nursing staff were coached to use the patient's preferred pronouns.

A review of the facility P&P titled, "PATIENT RIGHTS AND RESPONSIBILITIES," dated May 19, 2022, indicated, "...You have the right to: Considerate and respectful care, and to be made comfortable. You have the right to respect for your cultural, psychosocial, spiritual, and personal values, beliefs and preferences..."

Based on interview and record review, the facility failed to implement their policies and procedures (P&P) for six of 30 sampled patients (Patient 1, 2, 11, 14, 19, and 28) when:

1. For Patient 1, the nurse did not notify the physician and primary nurse of vital information to determine if Patient 1 was a danger to self;

2. For Patients 2, and 11, pain was not reassessed within 60 minutes after administration of pain medication;

3. For Patient 11, the nurse changed the standard alarm limits (50-120 bpm) to 40 on the cardiac monitoring machine without a physician order;

4. For Patient 14, the nurse did not notify the physician when Patient 14's heart rate parameter fell below the standard alarm limit of 50 bpm on the cardiac rhythm strips;

5. For Patients 14 and 28, the primary nurse did not verify, validate and sign the cardiac rhythm strips;

6. For Patient 19, pain medications were not administered for pain rated eight out of 10 (pain level, describes severity of pain, zero meaning no pain and 10 meaning the worst pain possible);

7. For Patient 28, there was no care plan to address restraints; and

8. For Patient 28, the nurse did not document vital signs (a measurement which shows how well your body is working and includes, heart rate, temperature, blood pressure, and respiration) in a timely manner.

These failures had the potential to compromise patient safety, resulting in poor pain management, and delays in medical care and/or death.

Findings:

1. A review of the facility document titled, "Incident Report," dated October 12, 2024, at 3:20 p.m., indicated, "...I USO [unit security officer, Name of Security Guard] observed siblings [Patient 1 and family member (FM)] check into the ER [emergency room] lobby with the Registered Nurse [RN]. Patient [Patient 1] had a bandage wrapped around her arm, and I overheard her telling the RN she had accidentally cut herself while wood carving. The FM immediately disputed that, and claimed the wound was self-inflicted, which caused patient [Patient 1] to begin shouting. Patient [Patient 1] yelled at the FM to leave the facility and called him a liar, which prompted me to intervene and ask the FM to step outside at 1522 [3:22 p.m.] hours. The FM informed me that the patient [Patient 1] cut herself with a razor about an hour prior to their arrival, and the FM showed me several photos on his phone confirming this. Patient [Patient 1] reportedly has a history of mental health issues and has been placed on legal holds in the past...The FM provided his phone number...and requested that I [Security Guard] inform the nursing staff about the situation. I [Name of Security Guard] went back inside to the ER nurse's station and informed the Clinical Nurse Manager [CNM] about the incident, and I [Security Guard] provided the CNM with the FM's contact number...Patient [Patient 1] returned to the lobby shortly afterward, and the FM drove off property..."

A review of Patient 1's medical record and a concurrent interview was conducted with the Manager of Emergency Department (MED) on March 5, 2025, at 10:22 a.m. The MED stated, Patient 1 was a triage level 3 (urgent, indicates a patient condition that is not life-threatening but requires prompt attention) and was asked all the suicidal ideation (SI) questions and answered no. If the SI questions were answered yes, report would be given to the back hall nurse who the behavioral health nurse is. The MED stated, there was no documentation in the medical record Patient 1 was brought into the ER by her FM and was suicidal.

A review of the facility document titled, "History and Physical (H&P)," dated February 26, 2020, indicated, "...61 YO [year old] F [Female] with hx [history] of depression and bipolar disorder presents with generalized body pain, worst in chest that began this morning after waking up. Patient 1 reports she was in a head on collision yesterday at 1500 [3 p.m.] on the freeway while driving, she ran into a large truck on the freeway...Documented Medications Effexor [medication to treat depression] XR [extended release] 75 mg [milligrams, unit of measure] oral capsule, extended release ...Clonazepam [medication to reduce anxiety] 1 mg oral tablet: BID [twice a day]..."

A review of the facility document titled, "Case Management Reassessment," dated February 28, 2020, indicated, " ...presenting issue- SWKR [Social Worker] consult for depression/anxiety, suicide attempt ...Patient does have a hx of making suicidal statements on 08/09/2013 [August 9, 2013] ..."

A review of the facility document titled, "ED Triage Form," dated October 12, 2024, at 3:34 p.m. indicated, "...Chief Complaint: LT [left] arm laceration from cutting wood per pt [patient] ..."

A review of the facility document titled, "ED Triage Form," dated October 12, 2024, at 4:32 p.m. indicated, "...CSSRS Pre-Screener [Columbia Suicide Severity Rating Scale, screening tool for patients requiring a suicide risk screening]...Suicide Present Sign Symptom BH [Behavioral Health] Cmplaint [sic]: No..."

Review of the facility document titled, "ED Note-Physician," dated October 12, 2024, dated 6:05 p.m., indicated, "...65-year-old female with history of depression and anxiety presents to ED for left forearm laceration that occurred PTA [prior to admission]. Patient states that she is recently started woodcarving as a hobby. Patient 1 was using a blade and accidentally cut her arm. Patient 1 was able to wrap it and control the bleeding."

An interview was conducted with Provider 1 on March 5, 2025, at 10:30 a.m. Provider 1 indicated, Patient 1 stated she took up a new hobby woodworking and cut her arm. The patient (Patient 1) said that's what happened, so he believed her. He was not told about the FM being outside or that she had SI. The plan for Patient 1's care would have been different had he known it was a suicide attempt.

An interview was conducted with the CNM on March 5, 2025, at 2 p.m. The CNM stated, "I don't remember this incident or being told about it. The process for a SI patient is they will get checked in by the pivot nurse and if they need to go back immediately, they call me, and I go talk to the Provider. If the FM says that to the pivot nurse, then the patient would go to the back and a consult for Social Worker would be done. I usually call for a 1:1 [one to one observation, one competent Constant Observer to one patient within line of sight] if it's a 5150 [involuntary hold of an adult when they are a danger to self or others]. We are supposed to triage these problems, but the patient is in charge of their care. If a family member told me a different story than the patient, then I would call the Social Worker to intervene and try to get the stories straight."

An interview was conducted with the Director of Emergency Department (DED) on March 6, 2025, at 9:20 a.m. The DED stated, if there was a suicide attempt, the nurse is supposed to notify the physician right away if the nurses were made aware, then the physician will initiate the Social Worker consult. The DED further stated, "We get all kinds of patients with cuts and injuries, but it will be up to the physician if they want to investigate it as self-harm."

A review of the facility policy and procedure titled, "STANDARDS OF CARE: ASSESSMENT, REASSESSMENT, AND CARE PLANS," dated March 3, 2025, indicated, "...The completed patient assessment establishes the foundation for the diagnosing/analyzing of patient problems, formulating a plan of care and determining appropriate referrals and reassessments...The patient is assessed/reassessed based on the following circumstances...Whenever there is a significant change in the patient's condition or diagnosis...Based on reassessment, the healthcare provider will modify/revise the patient's plan of care and education plan as appropriate...The medical provider will be notified of any significant changes in patient condition..."

2a. A review of Patient 2's medical record was conducted on March 4, 2025, at 3 p.m., with the Chest Pain Coordinator (CPC).

A review of the facility's document titled, "ED (emergency department) Note-Physician," indicated, Patient 2 arrived at the ED for a post op (operative, after surgery) surgical evaluation with sudden onset sharp pain around the right surgical drain.

A review of the facility's document titled, "Order Sheet," dated February 18, 2025, at 10:44 a.m. indicated, Acetaminophen (pain medication) 325 mg tablet, take 2 tablets orally stat (right away).

A review of the facility document titled, "MAR (medication administration record)," indicated, "...acetaminophen 325 mg [mg, unit of measurement] 2 tablets...orally...given on February 18, 2025...12:47 p.m..."

A review of the facility's document titled, "Pain Assessment," dated February 18, 2025, at 12:47 p.m. indicated Patient 2 did not have documentation of a pain level or reassessment.

On March 4, 2025, at 3 p.m. and interview and record review were conducted with the CPC. The CPC stated there was no documentation Patient 2's pain level were assessed and pain levels should be obtained prior to administration and reassessed 60 minutes after administration.

2b. A review of Patient 11's medical record was conducted on March 4, 2025, at 11:25 a.m., with the ARM.

A review of the facility's document titled, "H&P," indicated, Patient 11 was admitted to the facility on March 3, 2025, for diabetic ketoacidosis (acids build up in the blood to levels that can be life-threatening).

A review of the facility's document titled, "Pain Assessment," dated March 3, 2025, at 7:29 a.m., indicated patient 11 rated her pain 10 out of 10.

A review of the facility's document titled, "Medication Details," indicated, "...morphine 4 mg [milligram, unit of measurement] 1 ml [milliliter, unit of measurements]...IV push [Intravenous]...Given on March 3, 2025...08:04 a.m..."

A review of Patient 11's MAR indicated, there was no documented evidence a pain reassessment (checking patient's pain level to see if pain medication was affective).

On March 3, 2025, at 11:25 a.m., an interview and record review were conducted with the ARM. The ARM stated the nurse did not reassess pain 60 minutes after administering pain medication per policy. The ARM further stated there was no documented evidence the nurse reassessed pain in the Electronic Medical Record (EMR).

A review of the facility's P&P titled, "ADULT PAIN MANAGEMENT," dated December 19, 2024, indicated, "...To assure the adequate assessment, reassessment and treatment of pain for patients throughout the continuum of care...Reassessment of pain post [after] intervention is documented within 60 minutes after intervention..."

3. On March 3, 2025, at 9:35 a.m., a facility tour was conducted with the ARM, the MED, and the DED, the following was observed:

"I walked into room A after obtaining permission from the patient. I observed Patient 11 connected to a cardiac monitor; the heart rate was between 47 to 55 beats per minute. The audible alarm did not sound when the heart rate dropped as low as 47. I asked the MED if the alarms had been silenced, she checked the settings and stated, "it looks like the heart rate parameters was set at 40."

On March 3, 2025, at 10:03 a.m., an interview was conducted with the Emergency Department Registered Nurse 1 (ED RN 1). ED RN 1 stated, "I do not know who set the parameters, I did not, it must have been the night nurse." ED RN 1 further stated, "I did not see an order for the parameter to be changed to 40, I did not check it when I hooked the patient up this morning when she arrived. I did not notice that the machine was not sounding when falling below parameters."

On March 3, 2025, at 10:11 a.m. an interview and record review were conducted with the MED. The MED stated the parameters should have not be set at 40 without a physician order and further stated " I verified and there is no order for that setting." The MED further stated the nurse should have checked the parameters when hooking up the patient to the monitor, that is part of the assessment at the beginning of the shift. The MED stated ED RN 1 did not follow the policy, there is no order to change the parameter to 40 and there is no documentation that the physician was notified.

On March 3, 2025, at 10:14 a.m. an interview was conducted with the DED. The DED stated the nurse should not change the parameters without a physician order. The DED further stated the parameters should be set at 50-120.

A review of Patient 11's medical record was conducted on March 4, 2025, at 11:25 a.m., with the ARM.

A review of the facility's untitled document, dated March 3, 2025, at 7:36 a.m. was reviewed, the document indicated, "...Vent rate 46 BPM [Beat Per Minute]...PR interval [a measurement on an electrocardiogram] 166...QRS interval [the time it takes for the electrical impulse to spread through the ventricles]...Sinus bradycardia [a condition where the heart rate is slower than 60 beats per minute]...Abnormal ECG [Electrocardiogram, a test that records the electrical activity of the heart]..."

A review of the facility's P&P titled, "PATIENT CLINICAL ALARMS," dated August 18, 2021, indicated, "...The Registered Nurse (RN) must ensure that all alarms are set to activate at appropriate settings for each patient and are sufficiently audible with respect to distances and competing noise within the unit..."

A review of the facility's P&P titled, "DYSRHYTHMIA MONITORING," dated June 19, 2024, indicated, "...When notification parameters are not ordered and the patient's heart rate exceeds or is below the standard alarm limits (50-120), the physician must be notified...At the beginning of each shift, the RN will verify placement, proper functioning of the monitoring/transmitter, and check the battery indicator, if available. Assessment will be documented in the EMR..."

4. A review of Patient 14's medical record was conducted on March 4, 2025, at 3:04 p.m., with the ARM.

A review of the facility's document titled, "H&P," indicated, Patient 14 was admitted to the facility on February 28, 2025, for altered mental status (confusion) and pneumonia (infection in the lungs).

A review of the facility's document titled, "Vital Signs," dated March 1, 2025, at 10 p.m., indicated, "...Heart Rate...March 1, 2025, at 22:00 [10 p.m.] 41...Sinus Bra..."

There was no documented evidence in the EMR that the primary nurse notified the physician of the heart rate of 41, which fell below the order parameters.

On March 4, 2025, at 3:40 p.m. an interview and record review were conducted with the ARM. The ARM stated the nurse did not notify the physician when the heart rate went out of parameters. The ARM further stated there was no documented evidence found in the EMR that the nurse called the physician and received any new orders, the nurse did not follow the policy when reporting..."

A review of the facility's P&P titled, "DYSRHYTHMIA MONITORING," dated June 19, 2024, indicated, "...this policy is to facilitate appropriate, timely, and accurate electrocardiographic monitoring for those meetings the criteria specific to the nursing unit/department and/or physician direction...the patient's heart rate exceeds or is below the standard alarm limits (50-120), the physician must be notified..."

5a. A review of Patient 14's medical record was conducted on March 4, 2025, at 3:04 p.m., with the ARM.

A review of the facility's document titled, "H&P," indicated, Patient 14 was admitted to the facility on February 28, 2025, for altered mental status and pneumonia. Admit to ICU (Intensive Care Unit).

A review of the facility's document titled, "Vital Signs," dated March 1, 2025, at 10 p.m., indicated, "...Heart Rate...March 1, 2025, at 22:00 [10 p.m.] 41...Sinus Bra..."

There was no documented evidence the strip was printed, evaluated, signed and placed in the physical chart for the sinus bradycardia episode of 41.

On March 4, 2025, at 3:44 p.m. an interview and record review were conducted with the ARM. The ARM stated the nurse did not print, evaluate, sign and place the change in rhythm in the chart. The ARM further stated the nurse did not follow the policy.

5b. On March 5, 2025, at 11:15 a.m., a concurrent interview and record review of Patient 28's medical record were conducted with the Quality Analyst (QA). The facility document titled, "Admission H&P, " dated March 2, 2025 at 12:57 p.m., indicated Patient 28 was admitted to the facility on March 2, 2025, with diagnoses of intracranial hemorrhage (bleeding inside the skull that can put pressure on the brain), polycythemia vera (rare blood condition where the body makes too many red blood cells and can increase the risk of blood clots), Myocardial Infarction (heart attack, occurs when blood flow to part of the heart is blocked causing damage to the heart).

The facility document titled, "Alarm Review Report," dated March 3, 2025, at 8:56 p.m., was not signed by the RN. The QA stated, this report should be signed by the RN to acknowledge the patient's rate, rhythm and interpretation of the monitor strip.

The facility document titled, "Code Blue (a medical emergency where a patient is experiencing cardiac arrest, or another life-threatening condition that requires immediate resuscitation) Record," dated March 4, 2025, indicated, "...Time event Recognized: 0224 [2:24 a.m.]...Status when need for compression identified: Pulseless...First Rhythm Requiring Compressions: PEA [Pulseless Electrical Activity, medical condition where the heart's electrical system is working, but the heart is not pumping blood effectively]...Time Chest Compressions Started: 0224 [2:24 a.m.]..."

The facility document titled, "INFORMATION OF DECEASED," indicated, "Date of Death: March 4, 2025...Time of Death: 0243 [2:43 a.m.]..."

The facility document titled, "Discharge Summary...Death Discharge Note," dated March 4, 2025, at 10:57 a.m., indicated "...CAUSE OF DEATH- INTRACEREBRAL HEMORRHAGE..."

On March 6, 2025, at 11:30 a.m., an interview was conducted with the Clinical Manager of ICU (CM). The CM stated the rhythm stripe on March 3, 2025, at 8:56 p.m., was not verified, validated and signed by the RN and the policy was not followed.

A review of the P&P titled, "DYSRHYTHMIA MONITORING," dated June 19, 2024, was conducted. The P&P indicated, "...this policy is to facilitate appropriate, timely, and accurate electrocardiographic monitoring for those meeting the criteria specific to the nursing unit/department and/or physician direction...ASSESSMENT ON INPATIENT UNITS...The Monitor Technician will obtain, evaluate, and print a rhythm strip for each patient record. The RN will then verify, validate, and co-sign all printed strips... with any dysrhythmia that is new, symptomatic or reflective of a change from a previous rhythm, or that requires immediate intervention..."

6. A review of Patient 19's medical record was conducted on March 5, 2025, at 3:40 p.m., with the ARM.

A review of the facility's document titled, "H&P," indicated, Patient 19 was admitted to the facility on January 9, 2025, for pituitary mass (growths that develop in the pituitary gland) and headache.

A review of the facility's document titled, "Pain Assessment," dated January 10, 2025, at 8:26 a.m., indicated patient 19 rated his pain 8 out of 10, and the patient was not given pain medication.

A review of the facility's untitled document, undated, indicated, "...morphine [pain medication used for moderate to severe pain] 2 mg / [per] ml injection; 1 ml...2 mg 1 ml Push, Q [every] 4 hr [hours]...PRN [as needed], Pain Breakthrough Severe..."

A review of Patient 19's MAR indicated, there was no documented evidence the prescribed PRN pain medication for severe pain was given.
There was no documented evidence in the EMR that Patient 19's pain was addressed.

On March 5, 2025, at 4:05 p.m. an interview and record review were conducted with the ARM. The ARM stated there was pain medication ordered for the patient and the expectation would be for the nurse to administer the pain medication and reassess in an hour. The nurse did not follow the facility policy for pain management. The ARM further stated there was no evidence in the EMR that the pain was addressed.

A review of the facility's P&P titled, "ADULT PAIN MANAGEMENT," dated December 19, 2024, indicated, "...To assure the adequate assessment, reassessment and treatment of pain for patients throughout the continuum of care...Documentation of pain assessment consist of the following...Intervention done to relieve pain..."

7. On March 3, 2024, at 12:30 p.m., an observation was made in the Intensive Care Unit (ICU, unit where seriously ill patients receive close monitoring and specialized medical care). Patient 28 was observed to have bilateral wrist restraints.

On March 5, 2025, at 11:15 a.m., a concurrent interview and record review of Patient 28's medical record were conducted with the QA. The facility document titled, "Admission H&P," dated March 2, 2025, at 12:57 p.m., indicated Patient 28 was admitted to the facility on March 2, 2025, with diagnoses of intracranial hemorrhage, polycythemia vera and Myocardial Infarction.

The facility document titled, "All Orders," dated March 2, 2025, 5:48 p.m., indicated, "...Restraint Initiation Non-Violent...Interferes with Medical device...Soft limb...2 [two] Point Restraint, Restraint location: Bilateral Upper Extremity..."

The facility document titled, "Plan of Care," indicated there was not a care plan (an outline that details a patient's health needs and the steps healthcare providers will take to help meet those needs) to address the restraints. The QA stated a care plan to address restraints including remaining free from injury, skin integrity and positioning should have been in place for Patient 28.

On March 6, 2025, at 11:30 a.m., an interview was conducted with the CM. The CM stated that all patients in restraints should have a care plan in place to address the restraints and this was not done.

A review of the P&P titled, "STANDARDS OF CARE: ASSESSMENT, REASSESSMENT, AND CARE PLANS," dated March 3, 2025, was conducted. The P&P indicated, "...The patient's plan of care is initiated on admission and reviewed a minimum of every shift based on the patient's response to their specific assessed need for care and treatment...Patient care goals, needs, interventions, and response to care are reviewed (an updated as needed) and documented every shift..."

A review of the P&P titled, "RESTRAINT & [and] SECLUSION," dated January 18, 2024, was conducted. The P&P indicated, "...Monitoring and Reassessment...When Restraint or Seclusion is used, there must be documentation in the patient's medical record of the following...A description of the patient's behavior and the intervention used...Alternatives or other less restrictive interventions attempted...The patient's condition or symptom(s) that warranted the use of the Restraint or Seclusion...The patient's response to the intervention(s) used, including the rationale for continued use of the intervention...Individual patient assessments and reassessments...Use of Restraint or Seclusion in the Plan of Care..."

8. On March 5, 2025, at 11:15 a.m., a concurrent interview and record review of Patient 28's medical record were conducted with the QA. The facility document titled, "Admission H&P," dated March 2, 2025, at 12:57 p.m., indicated Patient 28 was admitted to the facility on March 2, 2025, with diagnoses of intracranial hemorrhage, polycythemia vera and Myocardial Infarction.

The facility document titled, "Vital signs," dated March 3, 2025, 6 p.m. through March 4, 2025, at 2:15 a.m., indicated the following:

-On March 3, 2024, at 6 p.m., heart rate 100 sinus tachycardia (occurs when heart beats faster than normal), respiratory rate 22, blood pressure 122/60;

-On March 3, 2024, at 7 p.m., heart rate 103 sinus tachycardia, respiratory rate 17, blood pressure 118/61;

-On March 3, 2024, at 8 p.m., heart rate 103 sinus tachycardia, respiratory rate 20, blood pressure 123/51;

-On March 3, 2024, at 9 p.m., heart rate 113 sinus tachycardia, respiratory rate 25, blood pressure 115/87;

-On March 3, 2024, at 10 p.m., heart rate 117 sinus tachycardia, respiratory rate 24, blood pressure 129/71;

-On March 3, 2024, at 11 p.m., sinus tachycardia;

-On March 3, 2024, at 11:15 p.m., heart rate 139, respiratory rate 33, blood pressure 123/69;

-On March 3, 2024, at 11:30 p.m., heart rate 124, respiratory rate 36, blood pressure 147/84;

-On March 3, 2024, at 11:45 p.m., heart rate 110, respiratory rate 36, blood pressure 147/84;

-On March 4, 2024, at 12:00 a.m., sinus tachycardia;

-On March 4, 2024, at 12:45 a.m., heart rate 128, respiratory rate 39, blood pressure 134/71;

-On March 4, 2024, at 1 a.m., heart rate 130 sinus tachycardia, respiratory rate 39, blood pressure 121/84;

-On March 4, 2024, at 2 a.m., heart rate 89 normal sinus rhythm (normal heartbeat), respiratory rate 28, blood pressure 100/63; and

-On March 3, 2024, at 2:15 a.m., heart rate 76 sinus tachycardia, respiratory rate 24, blood pressure 53/39.

Continued review of Patient 28's record indicated that all vital signs were documented on March 4, 2025, at 6:32 a.m. by the primary RN. The QA stated vital signs should be documented in real time and this was not done.

The facility document titled, "Code Blue Record," dated March 4, 2025, indicated, "...Time event Recognized: 0224...Status when need for compression identified: Pulseless...First Rhythm Requiring Compressions: PEA...Time Chest Compressions Started: 0224..."

The facility document titled, "INFORMATION OF DECEASED," indicated, "Date of Death: March 4, 2025...Time of Death: 0243..."

The facility document titled, "Discharge Summary...Death Discharge Note," dated March 4, 2025, at 10:57 a.m., indicated "...CAUSE OF DEATH- INTRACEREBRAL HEMORRHAGE..."

On March 6, 2025, at 11:30 a.m., an interview was conducted with the CM. The CM stated all vital signs for Patient 28 were documented late and the expectation is for the RN to document them as close to real time as possible. The CM further stated it is not acceptable to document all the hourly vital signs at once.

A review of the P&P titled, "CRITICAL CARE PLAN FOR PROVISION OF CARE AND SCOPE OF SERVICE," dated December 19, 2024, was conducted. The P&P indicated, "...Monitoring Documentation...Heart rhythm and rate...Every 1 [one] hour...Monitor strip interpretation...Every 12 hours with any change in rhythm...Blood pressure...Every 1 hour...Respiratory rate...Every 2 hours...Plan of Care...Every 12 hours..."